According to the Integrated Management of Childhood Illness (IMCI), severely ill children should receive initial treatment and urgent referral to hospital. However, if parents are unable to bring these children to a functioning hospital the risk of death is high.
In 12 health facilities in rural Uganda, Stefan Peterson from the Karolinska Institute, Stockholm, Sweden, Dr. Jesca Nsungwa from the Ugandan Ministry of Health, and colleagues recorded caretakers' ability to complete paediatric referral to hospital.
They found that two out of three severely ill children referred from health centres could not reach hospital due to lack of money, transport problems, or mothers' household responsibilities.
Children who failed to complete referral continued treatment at referring health centres or in the private sector. The researchers conclude that patient costs should be reduced, IMCI referral criteria be more strict, and that health centres should be empowered to care better for the many severely ill children they are already managing.
The quality of health care in district hospitals is thought to influence referral of children from local health centres, and to have a major influence on the overall effectiveness of a health system.
In an article in this week's issue (p 1948), Mike English from the Kenya Medical Research Institute and colleagues analysed data from 14 Kenyan hospitals. Inpatient mortality and case fatality rates varied widely between hospitals.
Often, cases were handled in ways that did not conform to national or international guidelines. Although missing data undermined the value of existing data, the authors conclude that even crude performance measures highlight the urgency of improving care, and tackling health systems' constraints at the first referral level.
In an accompanying Commentary (p 1922) Trevor Duke from the University of Melbourne, Australia, concludes: "The findings of the two studies published today indicate massive gaps between evidence, global strategies, and practice. The implications for adverse outcomes for children in developing countries, although not proven by such surveys, seem inescapable. Serious efforts need to be put into funding interventions to implement improvement in quality and to raise clinical standards in district hospitals, as part of a complete package of public child-health services. There could be few greater challenges for the future and relevance of global academic medicine than to work in partnership with ministries of health, service providers, local communities, and WHO to better understand these problems and implement and assess innovative solutions."
Contact: Dr. Stefan Peterson, Department of Public Health Sciences, Division of International Health, Karolinska Institutet, SE 171 76, Stockholm, Sweden; ) T): 46-70-446-0787;
E): stefan.peterson@phs.ki.se.
Dr. Jesca Nsungwa-Sabiiti, Child Health Division, Ministry of Health, Uganda T): 256-77- 509063;
E): jsabiiti@infocom.co.ug.
Dr. Mike English, KEMRI, KEMRI / Wellcome Trust Research Programme, PO Box 43640 00100 GP, Nairobi, Kenya; T): 254-2-271-0672; F): 254-41- 52-2390; E): menglish@wtnairobi.mimcom.net.
Dr. Trevor Duke, Centre for International Child Health, University of Melbourne, Department of Paediatrics, Royal Children's Hospital, Parkville, 3052 Victoria, Australia; T): 61-3- 9345-4977;
E): trevor.duke@rch.org.au.
Journal
The Lancet